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Insurance Covered my Reconstructive Plastic Surgery

Alright, I know this is the topic that everyone has been waiting for me to discuss. How I got my insurance to cover my plastic surgeries.

Let me first say that I have largely waited to talk about this very publicly until after the surgeries were done and after the bills were all paid. But I’m pretty comfortable at this point so I’m willing to discuss it a bit more. Let me say as an early Disclaimer; I was told every step of the way that my insurance would NOT cover these surgeries. I have been told by every professional involved that this was an unprecedented occurrence.

I also, knew very early on that having these skin removal surgeries was going to be a necessity for me for several reasons. The excess skin caused me pain and rashes that made exercise very difficult and that was problematic both for my weight loss, weight maintenance and my future career as a personal trainer. I knew from the beginning that if my insurance did NOT cover these surgeries I was going to have to figure out a way to pay for them.

So let’s talk first about what I was told by my insurance company and doctors going into this. I was informed by my insurance company that there was no coverage for elective plastic surgery and anything that was not “Medically Necessary” was considered elective. I was informed by both my Bariatric Surgeon and my Primary Care Doctor that I would have issues with excess skin. I was informed from as early out as the Orientation Seminar I had to attend that the only Reconstructive Plastic Surgery they were seeing the insurance companies approve was the panniculetomy; The surgery that removes the rather large part of the “stomach” that hangs down over the abdomen called the panniculus.

Prior to selecting a surgeon I consulted with two different plastic surgeons that I had heard speak at orientation seminars. Both plastic surgeons provided me with the same basic information. I’d be looking at anywhere between 3-5 different surgeries and my insurance would only be expected to cover the panniculetomy portion of the surgery.

Now the first big decision that I was faced with was what surgeon I was going to go with. I’m going to be perfectly honest, and though I won’t name the surgeon that I did not use, my reason for deciding not to go with that surgeon had to do with the fact that his surgery coordinator when I tried to discuss with her how I felt my insurance needed to be approached in regard to billing and about extenuating circumstances that I felt could very well lead us to getting the insurance to approve more than what anyone else expected, her response to me was “We don’t do it that way.” After speaking with the woman personally later and telling her why I chose a different surgeon she apologized for her words and informed me that I misunderstood her and that she would have done anything necessary to get the insurance approval. Her words didn’t imply that however, and they sent me searching for a surgeon that was going to work with me on working with my insurance. This after all was going to mean the difference of like .. lets just say A LOT of money. Could you blame me?

I decided I was going to consult with a different Surgeon so I contacted one of the other bariatric surgery centers of excellence in the area and asked them who they referred their patients too. That’s how I ended up meeting Dr. Shannon O’Brien at the Waldorf Center. I selected Dr. O’Brien as my surgeon for two major reasons; she was willing to do more work in less surgeries, which overall meant less time and money for me and she was willing to listen to me about the fact that I really felt my insurance should and would, if it was approached correctly, approve my surgeries.

Now let’s talk about my “extenuating” circumstances. I had an incident as a teenager that likely wrote me a fast check to obesity without my even realizing it. After failing physical education my freshman year of High School I had to attend summer school to make up for it. Summer school PE consisted of a 2 hr class that lasted I dunno 8 weeks or something and consisted of pretty much the students walking around the football field over and over again for 2 hours. The Teacher watched, and did whatever he did on his clipboard, planning football plays for the next season, who knows. After about three days of this 2 hr class I started to get a rash on my arms. Next it started to appear between my chest and my neck. Once it started to appear on my hands my Mother took me to the doctor who informed us that I was photosensitive, or “allergic to the sun,” as he put it. This got me out of PE for the rest of my High School career and opened up another elective slot for me which is why I got to do so much academic participation. It’s also probably why I never got a chance to learn that I might enjoy exercise or that I loved to run. I wonder sometimes what would have happened, changed or been different in my life if someone had helped me find my love for running when I was fourteen instead of thirty-four.

This sun allergy never really bothered me too much through my teens and twenties. Being as big as I was it wasn’t like I spent a lot of time in the sun or outdoors at all for that matter. When it did start to rear its head again was when Jason and I were first married back in 2003. We were spending a lot of time outdoors letter boxing when I had lost a bunch of weight and even as I started gaining it back, we still stayed pretty active we just did shorter walks and easier hikes. When we got back from a two-week camping trip in the summer of 2005 and my face looked like something off that movie “Mask” with Cheer and the boy with the distorted head, I knew it was time to start bugging my doctor. After a lot of tests, a Dermatologist finally diagnosed me with Discoid Lupus – in case you aren’t familiar with what that is I have provided a link. Some doctors believe that it was the skin disorder that Michael Jackson had that began altering the pigment of his skin and turned him to plastic surgery to begin with. It is also the same skin condition that the Singer Seal has been diagnosed with. For me personally, it manifested itself in this red bumpy risen rash in any area where the sun touched my skin, where I sweat a lot, or where my skin touched. This became a very problematic issue for me in areas like where my excess skin caused folds. I started to get sores anywhere that my skin touched; under my armpits, under my breasts, between my thighs, on my  mons, on my labia. Even at times on the backs of my thighs and on my stomach itself.

Now at this point, I started laying the ground work for where I knew I was going to be going. Every doctor that I saw, I talked to them about my weight loss and my skin issues and the health problems that it caused me. As an example, I had to see my OBGYN as part of my pre-op medical requirements for my gastric bypass. When I saw her, I let her know what I was about to do. Every time I saw her after that, whether it was for a bump or an annual exam, I mentioned the excess skin issues to her and discussed how they affected my female hygiene. Same with my primary care doctor, anytime I went to see him about anything, I had him document whatever bumps, sores, rashes or other skin irritation I had going on at the time. I talked to my dermatologist, my PCP, my OBGYN, and of course my Bariatric Surgeon. I made sure I took pictures, lots of pictures, of every bump, rash, infection, anything that could be blamed on the excess skin on my body, I documented the hell out of it.

I had talked to my insurance company upfront and they had told me something that I feel was key in our success. Even my surgeons office was shocked at what my insurance company approved. But from the very beginning they kept stressing this to me: My insurance covered nothing pre op and nothing post op, they covered only the surgery at a $25,000 lifetime maximum. They were very strict about this. Very strict. They did not cover anything pre-op for my Gastric Bypass. They also do not cover my post op follow-up after the initial 90 days after surgery. So my one year follow-up and any lab work that has to be done, are all on my dime. The thing I found interesting though, and where I started thinking outside the box was when my insurance said they covered any “Complications” and that the $25,000 lifetime maximum did not apply to covered complications. I asked my insurance company “Wouldn’t excess skin be a complication of Gastric Bypass surgery? I mean I wouldn’t have excess skin if I had not lost all this weight and I’d not have lost all the weight if i had not had the Gastric Bypass.” They didn’t confirm that for me, in fact their answer was sort of vague, but it was enough for me to know that I needed to find a Surgeon who was willing to look at my skin removal surgeries as a medical necessity and as a complication of Gastric Bypass surgery if I wanted to see my insurance cover it.

I shared my suspicious with my Surgeon from go about how my medical insurance needed to be billed and how i thought it needed to be looked at as a complication of surgery that also caused complications with my pre-existing discoid lupus. I’d love to get my hands on the paperwork that went from my surgeons office to the insurance company and be able to say “This is what worked.” All I know for sure is that all three of my surgeries have been covered by my insurance company. I never had to submit any photos or anything like that, I got my approval based on what my surgeon submitted on the first surgery.

The insurance denied us the first time we submitted to them on the second surgery. When I spoke to them, they said that they did not feel there was enough documentation regarding the skin issues that we were treating and asked for more documentation that the surgery was medically necessary. After a discussion with my surgeon where we both agreed that the implants I was planning to get were not medically necessary, but the rest was, she wrote a letter to the insurance company that stipulated as much and within a few days we had the approval and were ready to go. My final surgery, the thigh surgery I just did last week, was also approved on the first try. I never had to submit an appeal or anything like that through the entire process.

Financially, my insurance covered the first surgery at 80%, it covered the second and third surgery at 100% because I had reached my out-of-pocket max for the year. Now people ask me what the plastic surgery has cost me total. That’s really hard for me to answer because there are other expenses than just what you pay doctors. There is also the issue of time off. And I had to take quite a bit of time off after the first surgery. What I can say, is that so far, I took out a loan for $22,500 to fund my first surgery, before we got the insurance approval. So far, we have used the funds from that loan to pay our portion of the first surgery and to cover the time that I’ve taken off for all three surgeries. To date, so far we have used $17,500 of the loan funds. Considering the fact that I fully expected that loan to only cover the first surgery and that we have been able to use to pay our portion and cover my time off from all three surgeries this year, I consider that quite a feat.

I want everyone to understand that I am NOT in any way saying that your insurance will approve your plastic surgeries if you approach things the way I did. I’m 100% confident that it was a combination of my Discoid Lupus causing even more medical issues with my excess skin and it being considered a complication of Gastric Bypass surgery that convinced my insurance to approve these surgeries. That is a very unique combination and one I highly doubt most can mimic. I think the lesson here is that you need to think outside the box and communicate very well with those involved. I think it is very important to have several doctors willing to advocate for you; When I spoke to the nurse that worked on pre-approvals at my insurance company after they denied the second surgery and she told me that they wanted more documentation on the skin issues that the surgery would treat and more clarification that it was medically necessary, I asked her. “Would you like a letter from my PCP. OBGYN, Dermatologist, or Bariatric Surgeon?” I heard her chuckle a little before she said “Any of those would be fine, a clarification letter from the Plastic Surgeon would work as well.”

I believe that insurance companies should be covering these reconstructive surgeries. The emotional and physical benefits from me having these surgeries must out weigh the costs in the long-term. I’d love to see someone do some research in this area to help start to push insurance companies in that direction. What I do know is that my insurance company covered all of my surgeries thus far, and if I only ever had done what they covered, I would be ok with that for sure. I consider myself very lucky to have gotten what I got done with the help of my insurance. I’m also very passionate about trying to make sure that others are as fortunate as I was. So if there is any advice that I can give you based on my own journey, it is to explore every option and communicate really well with your insurance company and Surgeon. Push your surgeon to at least try to submit based on medical necessity and to appeal at least once as well.

That’s my experience with my insurance company and getting my surgeries approved. If you have any questions please feel free to use the comments section and I will try to answer them the best I can!

Post Reconstructive Thigh Lift

Okay folks, I’m doped up on Oxycodone as I sit here with my legs strategically positioned to cause me the least amount of pain possible trying to recover from yesterday’s Thigh Lift.

Okay so I’ve always said that when I got to the end of these plastic surgeries that I would discuss it all honestly and bluntly, so that’s what I’m going to do…

So first let’s talk about pain. But to do that we need to establish my pain threshold. I’m a whinny little twit when it comes to pain, if it hurts in the slightest I’m going to let you know about it, in great detail, repeatedly. That said I also have a pretty high pain tolerance. I’ve done a lot of painful things in my life. Had my appendix taken out, had a hysterectomy, had my tonsils removed, wisdom teeth pulled. I’ve broken fingers, broken ankles, broken feet.

I used to have menstrual cycles pre hysterectomy from endometriosis that would literally drop me to my knees bent over on the floor in pain. I used to have back pain so debilitating it would make me have to sit down and rest in the middle of cooking dinner.

My Gastric Bypass in 2010, was a walk in the park, I was up and walking the hospital floor three hours after surgery and had no problem moving around and within a week or two I was in the gym killing it again.

But Excess Skin removal surgery – by far the most painful thing I have ever experienced in my life.

Each Excess skin removal surgery that I have done, had its pros and cons. So far each one has had different complications and issues.

Let’s talk about my most painful though; the Thigh Lift. My Surgeon, Dr. Shannon O’Brien from the Waldorf Center of Plastic Surgery, did a Y incision on me. That means the incision comes up the inside of both my thighs, and then comes up the inside fold of my thigh and my groin in both directions, forming the top of the Y. As far as I can tell, which is guessing because I’m only a day out and I haven’t gotten a really good look at the incision line just yet, but I’m guessing it goes along that inside crease of my groin and my thighs to about the middle of my labia.

I have two drains after this surgery. They are located pretty much right along the bikini line incision from my 360 Body Lift earlier this year. If you imagine the V of your pubic region as you are standing, the drain sites are at about mid-point up on the V.

So the positive parts of this surgery thus far:

1. I was able to do this surgery outpatient, didn’t have to stay at the hospital and made it home the same night as surgery.

2. While this surgery is by far the most painful, it is also the easiest to get comfortable from. That may sound a bit strange, but with the incisions where they are, moving is excruciatingly painful, but if I get into a comfortable position, which is easier with these incisions that it was with the others, then I’m in absolutely no pain.

Now the negative:

1. This is by far the most painful thing I have ever done. The incisions make it ridiculously hard to move. Thank goodness I have my arms to help. The incisions are very tender, they burn, a lot. And anytime I move they just burn more. Getting comfortable is very tricky, but as I mentioned in the positives, I think it is easier to get comfortable after this surgery than it has been after the others. So it’s the most painful and the least painful at the same time. That has both its good and bad points.

I find that the most comfortable position for me, at least at this point, is sitting or laying in a recliner with the feet up. We can adjust my back to the right angle to make sure there is no pressure on my hips or thighs. Then we take these squishy pillows and put them under my knees to get each one in just the right position. I find that I’m much more comfortable when my knee is swaddled by a pillow. But the most important thing I have found in making sure that I am as comfortable as possible is that my ankles need to be level with my knees.

2. The Pain, when you move, is unbearable. It really is, I have no other way to explain it. It’s so bad that I am listing it twice as a Negative aspect. The first time they stood me up after surgery in the hospital and wanted me to try to walk to the bathroom, but when the nurse saw the look on my face just trying to stand, the pain on my face was unmistakable, and we ended up bringing in a bed side commode. Now, I will say that as I have pain meds on board and I don’t try to tucker through without it and let the pain sneak up on me, it gets a little easier. But as of Day 2 getting up out of the chair I am in, walking to the bathroom, sitting down, getting back up, walking back to the chair, which is maybe 12 steps each way, and sitting back down in that chair is enough to make me nearly want to pass out in pain.

3. The Compression Garments make me want to pull my hair out. They are crotchless, but that hole is nowhere near where it needs to be for everything to come out right. So unless you are alright with soaking the pants you can’t take off for three days at the earliest to shower with urine, you might want to go ahead and take the route I did, unhook and unzip the sides, take them down, do your thing, then pull them back up. It makes the bathroom routine way longer and contributes to it being a miserable experience, but the alternative sucks too. I just have to remind myself that this too shall pass and what drives me nuts right now won’t even matter to me two weeks from now.

4. I need help doing EVERYTHING. Getting up out of the chair, walking, sitting down. I’ll let you put two and two together here, but let me just say, make sure whoever is taking care of you afterwards is someone who loves you; they are going to have to get very up close and personal with you. I’ve been very lucky in that I have like the best girlfriend in the world and have had the same person to take care of me through all of my surgeries.

It’s been really hard for me to even get this post written because I doze in and out constantly because of the pain medication I’m taking. I’m usually the person that doesn’t really like to take pain medication, but man this time I’m taking it on the clock when I’m due for it, just to try to keep the pain managed. I’m outside my own box here, but I think it’s a good thing.

The first day home from the hospital was horrendous. Every time I moved I wanted to cry. Today, day two has been a little bit better, it hurts a little less to move today than it did yesterday.

It’s a little easier to get comfortable today than it was yesterday. I just keep reminding myself that in a couple of months, none of this will be hurting like this, and I’ll be able to wear shorts this summer. I hope… I haven’t actually gotten to see my thighs yet, so we’ll see. I’ll let you know.

I need to have Heather proof read this before I post it and make sure I made sense through my pain medicated rambling. 🙂

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Author: Pandora Williams

Author of Desperately Seeking Slender

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